SECTION A - NOMINEE PROFILE (to be completed by the Nominee or Nominating Organization)

First Name *
Last Name *
Preferred Mailing Address *
Address 1 *
Address 2
City *
State *
Zip *
Phone *
Phone (cell) *
Fax *
E-mail *
Currently a member of the NC Medical Society and for how many years?

Currently a member of which county society and for how many years?

Currently a member of which specialty society and for how many years?

Please list county, specialty, and/or NCMS activities in which the nominee has participated (i.e. committee member, section member, etc.) and/or held a leadership position (i.e. committee chair, AMA delegate, county officer, etc.)

Please list the nominee's membership in other medical associations.

Please list any medically related leadership positions held in the community.

Hobbies / Special Interests

SECTION B - NOMINEE Assesment (to be completed by the Nominee)

Please describe your interest in the Leadership College, including why you should be chosen by the Curriculum Advisory Committee to participate.

(please limit to 250 words)

Please provide a brief description of the top three issues physicians/physician assistants face today and the opportunities for leadership.

(please limit to 250 words)

The purpose of Leadership College is to assist you in gaining skills to serve a leadership role locally, regionally or statewide. What are three of your personal leadership goals?

(please limit to 250 words)

Please describe how your participation in the NCMS Leadership College will benefit your county and/or specialty society or the NCMS.

(please limit to 250 words)

In addition to participating in your county or specialty society, are you interested in participating in North Carolina Medical Society committees, task forces, projects or leadership positions?

Yes

Please include any supplementary materials you would like for the Curriculum Advisory Committee to review concerning this nomination.

Please include your current CV for our record and a recent headshot to be used in Leadership College publications and on the website.

Upload your current CV for our records.

Please upload a photo for use on publications/LC website.

SECTION C - NOMINATING ORGANIZATION (To be completed by the county society, specialty society or NCMS)

Nominating Organization's Name *
Name of person(s) completing form

Title(s)

Address 1 *
Address 2
City *
State *
Zip *
Phone
E-mail
Please describe why you believe the nominee should be selected by the Leadership College Curriculum Advisory Committee for participation in the 2012 NCMS Leadership College. Please include interactions with the nominee that demonstrate leadership capabilities and/or potential.

To the best of your knowledge, is the physician a respected clinician in his/her community? Explain.

To the best of your knowledge, membership information relative to the nominee and your society is accurate and complete.

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SECTION A - NOMINEE PROFILE (to be completed by the Nominee or Nominating Organization)

SECTION B - NOMINEE Assesment (to be completed by the Nominee)

SECTION C - NOMINATING ORGANIZATION (To be completed by the county society, specialty society or NCMS)